Is Any Type of Smoking Safe?

Tobacco hurts and kills people. In fact, smoking causes about 1 in 5 deaths in the United States.

There are many forms of tobacco on the market, and people often think some forms are safe and don’t cause health problems. This isn’t true. There is no safe form of tobacco.

Light, hand-rolled, natural, or herbal cigarettes

Smokers once believed that “light” and “low-tar” cigarettes had lower health risks. But studies have shown that the risk of serious health effects is not lower in smokers of light or low-tar cigarettes. Because of this, the US Food and Drug Administration (FDA) has banned use of the terms “light,” “mild,” and “low” in any cigarette sales unless the FDA specifically allows it − and so far, it hasn’t.

Hand-rolled cigarettes are no safer than commercial brands. In fact, life-long smokers of hand-rolled cigarettes have a higher risk of cancers of the larynx (voice box), esophagus (swallowing tube), mouth, and pharynx (throat) when compared with smokers of machine-made cigarettes.

Some cigarettes are now being sold as “all natural.” They’re marketed as having no chemicals or additives and rolled with 100% cotton filters. There’s no proof they are healthier or safer than other cigarettes, nor is there good reason to think they would be. Smoke from all cigarettes, natural or otherwise, has many chemicals that can cause cancer (carcinogens) and toxins that come from burning the tobacco itself, including tar and carbon monoxide.

Even herbal cigarettes with no tobacco give off tar, particulates, and carbon monoxide and are dangerous to your health.

Menthol cigarettes

Menthol cigarettes are not safer than unflavored cigarettes. In fact, they could be even more dangerous.

Menthol cigarettes tend to be “easier” to smoke – the added menthol produces a cooling sensation in the throat when the smoke is inhaled. It lessens the cough reflex and covers the dry feeling in the throat that smokers often have. People who smoke menthol cigarettes can inhale deeper and hold the smoke in longer.

The specific dangers of menthol cigarettes are an active area of research, but they are at least as dangerous as unflavored cigarettes.

Cigars and little cigars

Many people view cigar smoking as more sophisticated and less dangerous than cigarette smoking. Yet one large cigar can contain as much tobacco as an entire pack of cigarettes.

Most cigars are made of a single type of aged, air-cured or dried tobacco that’s fermented in a multi-step process. The fermentation causes chemical and bacterial reactions that change the tobacco. This is what gives cigars a different taste and smell from cigarettes. Cigars come in many sizes:

The smallest, known as little cigars or small cigars, are about the size of cigarettes. Other than the fact that they are brown and maybe a little longer, they look like cigarettes. They come in flavors like mint, chocolate, or fruit, and many have filters. They’re often sold in packs of 20. Most people smoke these small cigars exactly the same way as cigarettes.

Slightly larger cigars are called cigarillos, blunts, or cheroots. They contain more tobacco than little cigars, and are also often flavored. Studies suggest that some people smoke them more like cigarettes than cigars, inhaling and smoking every day. They look like small versions of traditional cigars, but they can be bought in small packs.

True large cigars may contain more than half an ounce of tobacco – as much as a whole pack of cigarettes. It can take from 1 to 2 hours to smoke a traditional large cigar.

Almost all cigarette smokers inhale, but most larger cigar smokers don’t. This could be because cigar smoke tends to irritate the nose, throat, and breathing passages. A new trend among cigar companies is to change the fermenting process to make cigar smoke easier to inhale. The filters on the smaller cigars also help smokers inhale.

There’s a lot of nicotine in cigars

Full size cigars can have as much nicotine as an entire pack of cigarettes.

Cigarettes have an average of about 8 milligrams (mg) of nicotine, but only deliver about 1 to 2 mg of nicotine to the smoker.

Many popular brands of larger cigars have between 100 and 200 mg, or even as many as 444 mg of nicotine.

No matter the size, cigars are tobacco, and they contain the same cancer-causing substances found in cigarettes. All cigars are dangerous to your health.

Smoking more cigars each day or inhaling cigar smoke leads to more exposure and higher health risks. The health risks linked to occasional cigar smoking (less than daily) are less clear. Like cigarettes, cigars give off secondhand smoke, which is also dangerous.

Clove cigarettes (kreteks)

Clove cigarettes, also called kreteks (KREE-teks), are a tobacco product with the same health risks as cigarettes. Kreteks are imported from Indonesia. They contain tobacco, ground cloves, clove oil, and other additives.

Like other flavored cigarettes, kreteks are used mostly by younger smokers. They are nearly ideal in design as a “trainer cigarette” – giving kids another way to try tobacco and get addicted to nicotine. The false image of these products as clean, natural, and safer than regular cigarettes seems to attract some young people who might otherwise not start smoking. But they are not safer than cigarettes, and researchers are looking into whether the cloves might even cause additional problems.

Kreteks have been linked to lung problems, such as lower oxygen levels, fluid in the lungs, and inflammation. Regular kretek smokers have up to 20 times the risk for abnormal lung function (blocked airways or poor oxygen uptake) compared with non-smokers.

Bidis (flavored cigarettes)

Bidis or “beedies” are thin, flavored cigarettes that originated in India and other Southeast Asian countries. They are hand-rolled in an unprocessed tobacco, tendu, or temburi leaf (plants native to Asia) and may be tied with colorful strings on the ends. They’re fairly popular with young people in the United States. This is in part because they are sold in candy-like flavors such as chocolate, cherry, strawberry, licorice, and orange. They tend to cost less than regular cigarettes and they give the smoker a quick buzz from the high levels of nicotine.

Even though bidis have less tobacco than regular cigarettes, they deliver 3 to 5 times more nicotine than regular cigarettes, as well as other harmful substances, such as tar and carbon monoxide. They are unfiltered. And because they are thinner than regular cigarettes, they require about 3 times as many puffs per cigarette.

Some people think they are safer and more natural than regular cigarettes. But bidis appear to have all of the same health risks of regular cigarettes, including many types of cancer. Bidi smokers have much higher risks of heart attacks, emphysema, chronic bronchitis, and cancer than non-smokers.

Hookahs (water pipes)

Hookah is also called narghile (NAR-guh-lee) smoking. It started in Asia and the Middle East. A water pipe is used to burn tobacco that has been mixed with flavors such as honey, mint, licorice, molasses, or fruit, and the flavored smoke is inhaled through a long hose. Usually, the tobacco mixture, which is called shisha (SHE-shuh), is heated using charcoal. (The charcoal itself produces carbon monoxide and other toxins.)

Hookah smoking has become popular among younger people in the US as a social event which lets the smokers spend time together and talk as they pass the mouthpiece around.

Newer forms of hookah smoking include steam stones that have been soaked in fluid and are used instead of tobacco and battery powered hookah pens. Both of these create a vapor that’s inhaled. Hookah pens work the same way as electronic cigarettes. Some sellers advertise that these are purer and healthier alternatives to regular hookahs, but this has not been proven.

Hookahs are marketed as a safe alternative to cigarettes. This claim is false. The water does not filter out the toxins. In fact, hookah smoke has been shown to contain toxins like carbon monoxide, nicotine, tar, and heavy metals, in concentrations that are as high, or even higher, than those in cigarette smoke – it carries many of the same health risks.

Several types of cancer, including lung cancer, have been linked to hookah smoking. It affects the heart, too, causing coronary artery disease, an increased heart rate, and high blood pressure. Lung damage, carbon monoxide intoxication, chronic bronchitis, emphysema, dental problems, and osteoporosis have also been linked to hookah use. There’s also a risk of passing infections while sharing a hookah.

Hookahs also put out secondhand smoke from both the tobacco and the burning charcoal used as a heat source.

Electronic cigarettes

Electronic cigarettes (e-cigarettes) are a form of electronic nicotine delivery system (ENDS). They are small battery-operated devices that look like cigarettes. When the smoker puffs on it, the system delivers a vapor of flavorings, nicotine, and other chemicals. The vapor is inhaled like cigarette smoke, and the nicotine is absorbed into the lungs.

The e-cigarette boom has led to sales of other ENDS designed to mimic other types of smoking using vaporized liquids. They look like cigarettes, cigars, pipes, or even pens or USB memory sticks.

Electronic cigars (e-cigars) look like large cigars, right down to the glowing tip partly covered by fake ash. Unlike e-cigarettes, e-cigars are often wrapped with a real tobacco leaf and are sold as disposable, rather than refillable.

Colorful “vape pens” or “e-hookahs” vaporize nicotine solutions often flavored like fruit and candy, which appeals to youth.

E-cigarettes are often used as a way for a smoker to get nicotine in places where smoking is not allowed. This leads to dual users – people who use ENDS and traditional tobacco products – which could decrease the likelihood of quitting. Some people think ENDS can be used to help people quit tobacco, but little research has been done on this.

The makers of ENDS say that the ingredients are “safe,” but there are questions about how safe it is to inhale some substances in the ENDS vapor. And ENDS cartridges are not labeled with their ingredients, so the user doesn’t know what’s in them. The amounts of nicotine and other substances a person gets from each cartridge are also unclear and have been found to vary greatly even when comparing same brand cartridges from the same manufacturer.

When the solutions in ENDS are heated, they release acetaldehyde and formaldehyde – known toxins. The flavorings in the solutions may also be toxic. Studies have shown that e-cigarettes can cause short-term lung changes that are much like those caused by regular cigarettes. But long-term health effects are still unclear. This is an active area of research, but right now not much is known about the safety of these products.

Although the vapor from ENDS is not likely to be as bad as the smoke from burning tobacco, there are concerns because these products are not regulated. There are many differences in ENDS makers, and a lot of safety questions haven’t been answered yet. We do know that ENDS are designed to deliver nicotine, and nicotine is addictive. This strongly suggests that ENDS use will lead to nicotine dependence, which could lead to the use of other tobacco products.

The American Cancer Society cannot recommend e-cigarettes and other ENDS products to help people quit smoking because it isn’t yet known if they are safe and effective.

There are proven methods available to help people quit, including pure forms of inhalable nicotine as well as nasal sprays, gums, lozenges, and patches.

Until ENDS are scientifically proven to be safe and effective, ACS will support the regulation of ENDS and laws that treat them like all other tobacco products.

Centers for Disease Control and Prevention (CDC). Smoking & Tobacco Use. Bidis and Kreteks. November 24, 2014. Accessed at www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/bidis_kreteks/index.htm on November 6, 2015.

Centers for Disease Control and Prevention (CDC). Smoking & Tobacco Use. Hookahs. September 14, 2015. Accessed at www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/index.htm on November 6, 2015.

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